Hey all. I am writing my careplan for my patient. He fell though a sliding glass door(dont know how) fell across sawhorses and now has lacerations on his occiptal, and left upper arm. He had left arm irrigation and debridement with fasciotomy. The operation went successful and he is now on bedrest until seen by the neuro. He is experiencing shallow breaths, moderate edema in his left arms and hands, and apparently there a large amount of drainage coming from his left upper arm. He is on contact precautions and a fall prevention program. I have to come up with 5 nursing diagnosis, and work out the top 2. My teacher has been getting onto my class about 2 things, putting things in the incorrect order of importance, and also she doesnt want us to us at risk for that often, only when at risk for infection. So I want to write my diagnosis, or what I think they should be, and hopefully get some feedback about what you think, or any corrections you might have. Acute Pain, Risk for infection (related to the surgical wounds, and high wbc counts), Nausea, Impaired Physical mobility, Impaired Skin Integrity. So theres 5, that are fitting, however I'm not sure if they are in correct order or if something has a misplaced priority.
Mar 26, '07
Priorities are usually established with ABC's - Airway, Breathing and Circulation.
Two things you might consider a nursing priority. Ineffective Breathing Pattern and and Risk for deficient fluid volume deficit.
Pain is a good one. For me that's always priority #1. I don't know if that's right or not, but without adequate pain control nothing else happens.
I'm not sure if the nausea would take precident over the breating and fluid volume, so you might drop that one in favor of other priorities.
Mar 26, '07
I also forgot to add that they have down as a diagnosis: cellulitis, and back pain. So im not sure if that would raise risk for skin infection to number 1, or if it would even be an at risk since they have his down as having cellulitis.
Mar 26, '07
Thank you tweety, so does this look better? : Acute pain, risk for infection, ineffective breathing pattern, impaired skin integrity, impaired physical mobility.... my teacher told me to avoid using at risk for unless its infection... so thats the only reason i want to leave the fluid volume deficit out.
Mar 27, '07
nursing diagnoses are always based on the patient's signs and symptoms that you found after doing your assessment and data collection. why are you dropping the nursing diagnosis of nausea? if your patient has this as a problem, then you should care plan for it. why is the patient on fall precautions? if he is likely to fall then a diagnosis of risk for falls is appropriate. is breathing really a problem for this patient? does he have any other symptoms of ineffective breathing pattern other than the shallow respirations?
based on the nursing diagnoses you listed this is how they should be sequenced using maslow's hierarchy of needs:
- ineffective breathing pattern (physiological need for oxygen)
- impaired skin integrity (physiological needs for oxygen and nutrition)
- nausea (physiological need for nutrition and comfort)
- impaired physical mobility (physiological need for movement)
- acute pain (physiological need for comfort)
- risk for infection (anticipated need for protection)
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